Challenges in Surgery for Small Bowel Crohn’s Disease

Robin S. McLeodDepartments of Surgery and

Health Policy Management and EvaluationUniversity of Toronto

Pre-operative Considerations• Timing of Surgery

• Unless there is a free perforation, emergency surgery is rarely indicated in patients with CD

• If a bowel obstruction is due to a Crohn’s stricture, it will almost always settle with non operative treatment

• Perforating disease with abscesses• Treat sepsis-drains, antibiotics, nutritional support

• Plan an elective or semi-elective procedure

Pre-operative Considerations• Image the GI Tract• Mark Stoma Site• Steroid Coverage, DVT prophylaxis, SSI preventionv Discontinuation of biologicals is probably not necessary

The “Routine” Ileocolic Resection

Principles:• Usually can be performed

laparoscopically• Remove all “gross disease”

and small margins of normal SB

• Stapled or handsewnanastomosis

The Difficult Mesentery

• Always be wary of the SB mesentery in Crohn’s disease• Take down all adhesions• Stay close to the bowel• Use the ligasure/energy

device for thick mesentery

Options:• Strictureplasty

• Heinecke Miculicz• Finney• Michelassi

• Resection

Multiple Strictures

Considerations• Is there sepsis present?• Is there a stricture at a previous

anastomosis?• How much bowel does the patient

have? (ie: has the patient had resections previously?)

• How much bowel would you have to remove if you resected the bowel now?

• Is it possible to perform strictureplasties (ie: is there enough normal bowel in between?)

• Resection plus strictureplasties might be an option

Heinecke Miculicz Strictureplasty

Finney Strictureplasty

Michelassi Strictureplasty

Strictureplasty• Reported complication rate 1-14%• Reported short term outcome is excellent• Re-operative rates (Hurst and Michelassi)

• 15% at 1 yr• 22% at 5 yr

• No consistent predictors of recurrence• ? Need for maintenance therapy

Surgery-free survival

70.7% (95% CI: 59.8-81.7)

26.6%(95% CI: 13.6-39.6)

Time (months)

• Antibiotics• Drain the Abscess• Nutritional support

• May need enteral nutrition or TPN

• Plan surgery semi-electively• ? Wait time variable

• May obviate need for a stoma

Perforation/Abscess

§ Sigmoid colon common site§ Others: small bowel, colon, bladder

and vagina§ Treatment options:

§ Repair the bowel/bladder§ Resection of the bowel

§ Big enterotomy/colostomy§ Lots of reaction§ Fistula is on the mesenteric

side of the bowel

Fistulizing Disease

Results – Secondary fistula site

ResultsPerforating

(n=293)Non-perforating

(n=142) P value

Duration of surgery, min + SD 140.5 + 47.5 117.3 + 36.1 <0.001

Laparoscopic approach, n (%)Converted, n(%)

157 (53.9)52 (33.1)

96 (68.1)7 (7.3)

0.004<0.001

Simultaneous extra resection, n (%)SigmoidSmall bowel

67 (22.9)589

0 (0)00

NA

Temporary stoma n (%) 35 (11.9) 4 (2.8) 0.002

Postop hospital stay in days, mean + SD 8.5 + 5.2 7.0 + 3.3 <0.001

ResultsPerforating

(n=293)Non-perforating

(n-142) P value

Total complications n (%)Anastomotic leakPostoperative AbscessWound infectionSBO/ileusGI bleedOtherSeptic (Leaks or Abscesses)

42 (14.3)7 (2.4)7 (2.4)9 (3.1)12 (4.8)4 (1.4)5 (1.7)13 (5.6)

24 (17.0)0 (0)0 (0)

9 (6.4)7 (5.0)4 (2.8)4 (2.8)0 (0)

00000000

Reoperation, n(%) 9 (3.1) 1 (0.7) 0.18

Mortality 0 0 NA

• Joe is a 22 year old male• developed Crohn’s disease as a child• multiple drugs and operations over the years• Significant growth retardation

• Transferred to me from the children’s hospital at age 18 years• Small bowel resection and ileosigmoid anastomosis• minimal perianal disease• Over the next few years:

• perianal disease worsened• Multiple fistulas requiring drainage procedures on several occasions

• recurrence at the ileosigmoid anastomosis • Short stricture causing obstructive symptoms

Patient Story

• Family Situation• Very supportive family• Mother always comes to office visits; often father attends• Joe has one older brother

• Studying law at university• Joe’s situation

• Finished high school but has not been able to undertake post-secondary schooling nor work because of his Crohn’s disease

Patient Story

• I recommend to Joe that he should have a proctectomy and permanent ileostomy

• Joe is undecided whether he wants to have surgery• He continues to have problems with his perianal disease and

intermittent obstructions• Joe is seen by one of our psychiatrists

Patient Story

• Joe tells the psychiatrist he is ambivalent about the surgery because he forsees that there are two possible outcomes:1. Unfavorable outcome:

• Joe views a stoma as his “last chance”• Currently he has hope because there is another option• But, if he has a stoma, and he continues to have problems, he

will be despondent because he won’t have anymore options2. Favorable outcome:

• He will not longer be “the sick child” and his family’s and his own expectations of him will be high

• Joe sees that both outcomes have risks for him

Patient Story

• Important to remember that Crohn’s disease is a chronic disease and surgery does not cure the patient of the disease.

• Thus, the question to the patient should not necessarily be: “What is the matter with you?”

but “What matters to you?”

Non OR Challenges